Ryuji Shichinohe

Advanced epithelioid malignant peripheral nerve sheath tumor showing complete response to combined surgery and chemotherapy: a case report.

Malignant peripheral nerve sheath tumor (MPNST) is a rare high-grade soft tissue sarcoma. The epithelioid variant accounts for 5% or less of MPNSTs; the clinical behavior of this variant is unclear. Reports of approximately 40 cases are available in the English literature; however, most reports addressed clinicopathological features rather than therapeutic procedures or clinical courses. We describe a case of a 62-year-old male with an epithelioid MPNST of the left foot. Multiple lung metastases developed after radical surgery on the primary lesion. The response to adjuvant chemotherapy including doxorubicin and ifosfamide was favorable, and thoracoscopic resection was subsequently performed on the remaining three metastases. No evidence of recurrence or metastasis was observed at the 12-month followup after the first operation. Further followup and chemotherapy may be required.

Review and proposal of regional surgical management for melanoma: revisiting of integumentectomy and incontinuity dissection in treatment of skin melanoma

BackgroundPast studies showed that integumentectomy and incontinuity could be effective procedures in the surgical management of melanoma patients. The present study reports on the historical background of these procedures. In addition, we analyze the ICG assisted integumentectomy and incontinuity techniques and algorithms that we had created when performing this procedure.MethodIn accordance with our algorithm, we performed ICG assisted integumentectomy/incontinuity procedures on 17 patients with stage III melanomas between 2008 and 2016. We also investigated the locoregional recurrence rate in a control group comprising 60 patients at stage III without using the algorithm.ResultsThe former group exhibited a tendency of locoregional recurrence rate suppression. Melanoma cells in the dissected intervening tissue were microscopically identified in 2 out of 17 cases.ConclusionsOur ICG assisted integumentectomy or incontinuity procedures could be effective in controlling locoregional recurrence rates in melanoma cases. Moreover, our method can be generally applied because the dissection is only performed within the lymphatic pathway region identified using indocyanine green.

Full-Thickness Entire Nasal Alar Reconstruction Using a Forehead Flap in Asians: No Cartilaginous Infrastructural Lining Is Necessary

Abstract Full-thickness defects of the entire nasal ala, including the rim, can be challenging to reconstruct. A forehead flap may provide a more imperceptible and natural-appearing reconstructed nasal ala. Previously, many authors have insisted adding cartilaginous infrastructural support for an entire, full-thickness defect to keep the postoperative alar structure symmetrical. They finally use a forehead flap after thinning of the distal covering portion subcutaneously, possibly for a Caucasian-type nasal ala. However, Asian skin has a thicker and more compact dermis than that of Caucasian skin, and the Asian ala is rounder and thicker. There may be another approach for an Asian-type nasal ala. The authors propose the possibility of nasal alar reconstruction for an entire, full-thickness defect in Asians using a forehead flap without structural support. Six patients with entire full-thickness nasal alar defects treated with full-thickness forehead flaps above the periosteum without structural support were reviewed. Five patients demonstrated esthetically good to excellent outcomes in color, texture, and symmetry. Their nasal linings were reconstructed using mucoperiosteal flaps or mucosal grafts. One patient treated with a nasal lining using a local flap showed a fair result esthetically. Asians forehead above the periosteum has adequate thickness and supportability to reconstruct the entire full-thickness nasal ala in Asians. No cartilage support is necessary.

Factors that Affected Functional Outcome After a Delayed Excision and Split-thickness Skin Graft on the Dorsal Side of Burned Hands.

Early excision and skin grafting is the principle treatment for a burned hand although there are occasions when it cannot be done such as severe general condition, delayed consultation, and the lack of a definitive assessment of burn depth. This study analyzes the factors that affected function after a delayed excision and skin graft for hands with a deep dermal burn. This study retrospectively evaluated 43 burned hands that required a delayed excision and split-thickness skin graft on the dorsal side. Cases were required to only have split-thickness skin grafting from the dorsum of the hand and fingers distally to at least the proximal interphalangeal joint at least 8 days after the injury. The hands were divided into two functional categories: Functional category A, normal or nearly normal joint movements, and functional category B, abnormal joint movements. Demographic data were assessed statistically by a univariate analysis following a multiple regression analysis by a stepwise selection. A significant difference was observed between the groups in the number of days from grafting to complete wound healing of the graft site and with or without an escharotomy in the analysis. These parameters were statistically significant predictors of functional category B. The functional outcome of a burned hand after a delayed excision and split-thickness skin graft on the dorsal side became degraded depending on the number of days from grafting to complete wound healing. Cases that underwent an escharotomy also showed deterioration in function.

Exploration of more effective neurorrhaphy in facial nerve reconstruction: A comparison focusing on the difference of neural window size and condition of the neurorrhaphy site.

BACKGROUND AND AIM Various techniques have been introduced for reconstruction of the facial nerve. An improved method of neurorrhaphy to achieve satisfactory mimetic muscle function is required. We made and compared three different neurorrhaphy models to elucidate the effect of neural window size and condition of the neurorrhaphy site on axonal regeneration. METHODS Rats were divided into four groups: group A, untreated incomplete palsy; group B, treatment by end-to-side neurorrhaphy through a small perineural window; group C, treatment by side-to-side neurorrhaphy through a large perineural window; and group D, treatment by side-to-side neurorrhaphy through a small perineural window. After surgery, mimetic muscle movement was evaluated. Retrograde-labeled neurons through the facial nuclei were counted, and mimetic muscle specimens were examined. The axon number was counted in nerve specimens. RESULTS The facial palsy scores of groups B and C were significantly greater than those of groups A and D. With regard to the number of neurons at the facial nuclei, groups B and C had more neurons than groups A and D. Group D had significantly more neurons than group A. With respect to the number of axons, groups B, C, and D had significantly greater numbers than group A, but there were no significant differences between the reconstructed groups. CONCLUSIONS Window size and condition of the neurorrhaphy site, which affected mainly the number of axons, influenced axonal regeneration in nerve reconstruction. This result indicates the possibility of obtaining a better result for facial nerve or other peripheral nerve reconstruction with a tidbit of operative artifice.

A new primary cleft lip repair technique tailored for Asian patients that combines three surgical concepts: Comparison with rotation–advancement and straight-line methods

Various techniques have been described for unilateral cleft lip repair. These may be broadly classified into three types of procedure/concept: the straight-line method (SL; Rose-Thompson effect); rotation-advancement (RA; upper-lip Z-plasty); and the triangular flap method (TA; lower-lip Z-plasty). Based on these procedures, cleft lip repair has evolved in recent decades. The cleft lip repair method in our institution has also undergone several changes. However, we have found that further modifications are needed for Asian patients who have wider philtral dimples and columns than Caucasians, while following the principles of the original techniques mentioned above. Here, we have incorporated the advantages of each procedure and propose a refined hybrid operating technique, seeking a more appropriate procedure for Asian patients. To evaluate our new technique, a comparison study was performed to evaluate RA, SL, and our technique. We have used our new technique to treat 137 consecutive cleft lip cases of all types and degrees of severity, with or without a cleft palate, since 2009. In the time since we adopted the hybrid technique, we have observed improved esthetics of the repaired lip. Our technique demonstrated higher glance impression average scores than RA/SL.

Reconstruction of Large Cheek Defect With/Without Sideburn Using Malar-Posterior Auricular-Cervico Flap.

AbstractThe cheek region is the most common site for malignant tumor occurrence and the treatment of malignant skin tumor requires extensive local excision. Many previous reports have covered methods of reconstruction using local flaps for skin defects in the cheek region.In this article, we describe our experience with a surgical reconstruction using a new flap method for 8 patients with missing tissue in the cheek region. This flap is based on the concept of separately designing the flap with the 3 areas comprising the malar, posterior auricular, and cervical regions. We named the flap containing these 3 regions the malar-posterior auricular-cervico flap. Esthetically satisfactory outcomes were achieved in all cases.In conclusion, we recommend our malar-posterior auricular-cervico flap to reconstruct the tissue defects of approximately 20 to 40 cm2 after tumor excision in the cheek region. If preauricular skin is included in the design of this flap, the sideburn can be reconstructed using a part of the nape region with hair.

Dynamic change of myogenin in denervated rat mimetic muscle.

We previously reported double innervation of rat mimetic muscles with labeling of facial nuclei. However, whether denervated mimetic muscles are affected after such nerve repair is not known. Rats were divided into five groups: Group A, controls; Group B, complete facial palsy; Group C, complete facial palsy with repair using end-to-end neurorrhaphy; Group D, incomplete facial palsy; and Group E, incomplete facial palsy with repair using end-to-side neurorrhaphy. Preoperatively and postoperatively, facial palsy and myogenin (Myog) expression in mimetic muscles were evaluated. Expression peaked on day 7 in Group B but was lower in Groups C and D. Expression in Groups D and E was comparable on day 28, and each models score showed characteristic changes. Myog expression in facial mimetic muscles increases with denervation and decreases with nerve repair. Determining Myog expression levels in mimetic muscles just after nerve repair may help surgeons predict postoperative prognosis in facial palsy.

A case of subungual keratoacanthoma

62歳男性。初診の半年前から右母指爪下に白色調の病変と周囲の発赤を自覚した。前医で爪の開窓および病変の掻爬処置を受けたが病変の再発を認め, 悪性腫瘍を疑われ当科を紹介された。初診時に右母指爪甲の表面は粗槌で中央部に爪甲欠損部を認め, 爪甲欠損部の中枢側に大きさ6×5mmの淡褐色の腫瘤が透見された。単純エックス線写真では右母指末節骨の骨破壊像が認められ, 右上腕内側には弾性硬の皮下腫瘤が触知された。爪下の腫瘍を切除し, 皮膚欠損部は人工真皮で被覆し, 二期的に分層植皮術を行い再建した。病理組織では有棘細胞様の胞体の広い細胞がカップ状に増殖し, 内腔に角化物を容れた像が認められ爪下ケラトアカントーマと診断した。